Innovation summary

The Text4Mood programme allows subscribers to receive daily supportive text messages which have been written by mental health therapists in collaboration with service users. This innovation addresses a lack of access to psychological therapies for patients with depression and anxiety complaints, including long wait times to access services and geographical barriers for patients in under-served remote locations.

Wait times for service
Daily supportive texts are sent to those on a waitlist for services. Although not a substitute for face-to-face service for those who require it, the Text4Mood program provides an immediate service for patients who would otherwise receive no assistance as per routine procedure, thereby effectively decreasing wait time for an intervention to zero.

Geographic/distance barriers
For those who may not be able to access services immediately when offered due to distance, they can subscribe to the Text4Mood programme to receive daily supportive texts until a service closer to their home is available. The technology is unaffected by geography.

Patients in Alberta can subscribe to and unsubscribe from the programme by simply texting a designated phone number. There is no charge to patients for receiving daily supportive text messages. 

Impact summary

  • In the first year of its launch, over 10,000 people subscribed to the Text4Mood programme.
  • 83% of subscibers felt the messages improved their overall mental well-being.
  • It costs $5.40 to deliver daily text messages to a patient for 6 months, compared to an average of $1800 for 12 sessions of face-to-face therapy in Alberta.

 

“When everything is going bad, that message brightens my day. I look forward to it every day.”

 

- Text4Mood programme subscriber 

Innovation details

The Text4Mood is an innovative programme because it provides a novel means to address common health problems, specifically wait time for mental health intervention and geographic barriers to service. Through the use of text messaging technology, Text4Mood provides an immediate service to persons who are on a waitlist or may have difficulty accessing service due to geographic barriers (e.g., underserved communities in Northern Alberta). The programme can also be used to offer complimentary psychological support for patients who are attending individual or group counselling. The technology is a relatively low cost, high impact, and easily scalable program that uses existing technology, is devoid of geographic barriers, and is free and accessible to end users.

Examples of supportive text messages sent to patients include:

  • If you keep on going, maintaining your hope and belief that something good will happen, it generally does. One day at a time.

 

  • Anger can be empowering when it’s properly channelled, use it as an ally in your recovery. It can give you the energy and motivation to get moving physically, mentally and emotionally.

 

  • Give yourself the time you need to recover, do not try to race ahead to where you think you should be, remember that time is a great healer.

 

  • There are two days in the week we should not worry about, yesterday and tomorrow. That leaves today, live for today.

 

  • Keep track of how many times a week you feel down. If you start feeling sad more often than not, then it might be time to take action.

A number of projects provided evidence for the benefits of this intervention before the program was launched.  Specifically, two clinical trials in Ireland and Canada1-3 suggested that daily supportive text messages have the potential to reduce depressive symptoms in patients with Major Depressive Disorder. A user satisfaction survey for the Irish study4 noted that 83% patients who received twice daily supportive text messages indicated that the intervention had played a useful role in helping to improve their mental health, in particular, in serving as a motivation for recovery.

In light of the positive outcomes observed in the two clinical trials, it was decided to launch a daily supportive text messages service (Text4Mood) for patients of Northern Alberta, which has a widely dispersed population with patients in remote locations usually having inadequate access to psychological or counselling services.  The online application allows subscribers to receive daily supportive text messages by simply texting the word “mood” to a designated number.  Subscribers can also unsubscribe from the programme by texting the word “stop” to the same number or in reply to any of the messages. There is no charge to subscribers for receiving daily supportive text messages.

Key drivers

Local research prior to implementation
Prior to the launch of the Text4Mood programme, a clinical trial1-2 was conducted in Alberta which provided local evidence of clinical effectiveness of the intervention for patients with depressive symptoms. The results of this trial, as well as evidence from other research, provided a compelling rationale to administrative leadership for sustaining this programme as a clinically useful and low-cost intervention for depressive symptoms, particularly in under-served rural Alberta.

Multi-stakeholder involvement
Collaboration with service users and mental health therapists working within Alberta Health Services, Addiction and Mental Health Department ensured that the bank of supportive text messages used for the Text4Mood program were relevant to alleviating symptoms of depression and anxiety as they were based on principles from cognitive behavioural therapy and the knowledge of people with lived experience. Collaboration with health services operational leaders, mental health clinicians, and service users at all levels of implementation ensured multiple stakeholder ownership and support for the programme.

Effective communication
The Alberta Health Services North Zone Communications department were instrumental in promoting the Text4Mood programme using multiple news and media outlets. This created an initial challenge of over-subscription to the programme. However, the high demand of the programme provided rationale for Alberta Health Services to fund and sustain the programme.

Challenges

Technical challenges related to over-subscription
Prior to the launch of the programme, it was anticipated that 500 individuals would subscribe within 6 months. However, over 4,000 individuals subscribed to the programme within 6 weeks of its launch. The challenge of subscription exceeding expectations resulted in text credits becoming exhausted earlier than anticipated. This was resolved quickly with Alberta Health Services providing funds to expand and sustain the programme. 

Evaluation methods

Impact was evaluated via an online survey link distributed to all subscribers to the Text4Mood programme on their 42nd day (six weeks) of enrolment. The link was sent to subscribers between the 1st of March 2016 and the 11th of April 2016.  A reminder text message with the survey link was also sent to all 4,111 subscribers of the Text4Mood programme on the 8th of April 2016, encouraging them to complete the survey. Participation in completion of the questionnaires was entirely voluntary and patients were not offered incentives for participation.

Survey questions were formulated based on available evidence from peer-reviewed literature to evaluate demographic and clinical characteristics of subscribers, as well as the reasons for signing up to the programme and the perceived impact of the programme on their mental wellbeing. The evaluation tool is available in the Resources section.

Draft survey questions were pre-tested with ten respondents (four of whom were clinically depressed) who were not enrolled in the Text4Mood programme. The survey questions were revised based on pre-test findings. Additional Likert scale responses were drafted from several of the open-ended questions. A second survey pre-test was undertaken on five additional respondents (two of whom were clinically depressed) and took participants approximately 5 min to complete.

Currently, new online survey questionnaires are being developed to continuously evaluate the programme. In the meantime, new subscribers to the programme are being tracked periodically. 

Cost of implementation

Although the Text4Support programme is not a replacement for psychotherapy and counselling for those who require it, an economic comparison can be made. It costs $5.40 CAD to deliver daily text messages to a patient for 6 months, compared to an average of $1800 CAD for 12 sessions of face-to-face therapy in Alberta. Furthermore, automated text messages can be delivered to thousands of patients simultaneously, compared to face-to-face counselling services which are labour-intensive.  Moreover, it is possible that a portion of patients who receive this service may show symptom improvement in the interim, and require less intensive therapy in the long-term. This is a hypothesis that remains for investigation.

Impact details

As at the first anniversary of the programme, over 10,000 subscribers had signed up for the Text4Mood.

The results from the online survey of 4,111 subscribers suggest the programme has been well-received by Albertans and has contributed toward improving the mental well-being of subscribers. In summary:

  • Most respondents were female (83 %, n = 668), Caucasian (83 %, n = 679), and diagnosed with a psychiatric disorder (38 %, n = 307), including depression (25 %, n = 227) and anxiety (20 %, n = 177).
  • Overall, 52 % (n = 461) signed up for Text4Mood to help elevate their mood and 25 % (n = 219) signed up to help them worry less.
  • Most respondents felt the text messages made them more hopeful about managing issues in their lives (82 %, n = 588), in charge of managing depression and anxiety (77 %, n = 552), and connected to a support system (75 %, n = 542).
  • The majority of respondents felt Text4Mood improved their overall mental well-being (83 %, n = 598).

References

  1. Agyapong V.I.O, Juhás M, Omeje J, Mrklas K, Suen V,  Ohinmaa A, Dursun SM, Greenshaw AJ Supportive text messages for patients with depression – A randomized controlled trial. European Psychiatry, Volume 41, Supplement, April 2017, Page s139
  2. Agyapong V.I.O, Juhás M, Omeje J, Mrklas K, Suen V,  Ohinmaa A, Dursun SM, Greenshaw AJ Randomized Controlled Trial of Supportive Text Messages for Patients with Depression BMC Psychiatry (2017)-In press
  3. Agyapong V.I.O., McLoughlin D. Farren C.K., Supportive text messaging for alcohol use disorder and comorbid depression: single-blind randomised trial.  J. Affect. Disord. Volume 141, Issues 2–3, 10 December 2012, Pages 168-176
  4. Agyapong V.I.O., McLoughlin D. Farren C.K., Perception of patients with Alcohol Use Disorder and comorbid depression about the usefulness of supportive text messages- Technol Health Care. 2013 Jan 1; 21(1):31-9. doi: 10.3233/THC-120707.
  5. Agyapong VIO, Mrklas K, Juhás M, Omeje J, Ohinmaa A, Dursun SM, Greenshaw AJ. Cross-sectional Survey Evaluating Text4Mood: Mobile health program to reduce psychological treatment gap in mental healthcare in Alberta through daily supportive text messages. BMC Psychiatry (2016) 16:378. DOI 10.1186/s12888-016-1104-2
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